Library

What are the clinical manifestations of Shanghan (Cold Damage)? It is said that when Shanghan is initially contracted, the pathogen enters the skin and hair. The Xuanfu (sweat pores) become obstructed, Qi cannot circulate freely, and there is no outlet for release. Consequently, the Qi of the Zang-Fu organs also becomes stagnant and generates heat. The so-called transmission to the interior occurs because the muscles fail to transmit properly. Within the muscles, there are Luo-Jin (collateral sinews) and Jing-Jin (sinew meridians), all extending inward to connect with the Zang-Fu organs. The Qi and Blood of the Zang-Fu organs seep and moisten the muscles through these structures; these are the sinews and vessels associated with the Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and Yuan-Source acupoints. Thus, pathogens transmit from the skin and hair to the muscles, from the muscles to the meridians and collaterals, and finally into the Zang-Fu organs. (The sequence of transmission between meridians and Zang-Fu organs is detailed in the Diagnosis section.) This is referred to as the transmission from Exterior to Interior. Furthermore, in the *Suwen* (Basic Questions), "meridian-to-meridian" transmission occurs because the Foot-Yang meridians run from head to foot and travel together, making transmission easy and sequential. "Cross-meridian" transmission occurs at points where the Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and Yuan-Source points intersect; when one meridian is deficient, the pathogen takes advantage and migrates. What the *Suwen* describes is the normal pattern, while cross-meridian transmission is a variant. Regarding transmission from meridians to Zang-Fu, for example, Yangming disease presents with eye pain, aversion to cold, fever, dry nose, and insomnia; this is a disease of the Yangming Stomach Meridian, known in Shanghan texts as Yangming Exterior Syndrome. Subsequently, if tidal fever, spontaneous sweating, delirium, thirst, epigastric fullness, dryness and excess, and hard stools appear, it indicates that pathogenic toxins have entered the Stomach, causing intense heat, complete drying of body fluids, and depletion of Stomach Yin, losing its moistening quality. This is what the texts refer to as proper Yangming Interior Syndrome. By this example, diseases of the Three Yang meridians can be inferred.

The so-called "direct invasion of Yin meridians" refers to the meridians of the Heart, Liver, Spleen, Lung, and Kidney being affected by severe cold air. From the meridians between the muscles, the pathogen directly forces its way into the Zang organs—whether Heart, Liver, Spleen, Lung, or Kidney—causing them to become cold as iron, with blocked Qi circulation, resulting in Yin Syndromes. At this time, hot medicines must be urgently administered to unblock the meridians according to their pathways, gradually warming the body so that the warm Qi in the Zang organs can communicate with the meridians between the muscles. By this example, diseases of the Three Yin meridians can be inferred. (Dongzhuang stated: Yin Syndromes are caused by cold pathogens directly entering the Three Yin meridians because the Qi of the Three Yang is weak and lacks heat to repel the cold. Each of the Three Yin has specific syndromes; however, people today label any illness occurring after sexual exhaustion as a Yin Syndrome without distinguishing Yin or Yang pulse and symptoms, causing patients to avoid mentioning these terms, which is laughable. Illnesses after sexual exhaustion involve deficiency and external contraction, having both Yin and Yang aspects, and are not necessarily Yin Syndromes.) There are many primary and transmitted syndromes in Shanghan; consulting the *Yizong Jinjian* will clarify them, so they cannot be fully listed here.

In treating Shanghan, only Taiyang Syndromes should use Mahuang Tang (Ephedra Decoction) to release the exterior. If thirst is present, it is no longer a Taiyang Syndrome. Because the Taiyang meridian runs along the back of the body, neck stiffness and headache indicate an Exterior Syndrome. Other conditions are unrelated to the exterior, and herbs like Mahuang for releasing the exterior should be contraindicated. Jiegu's Jiuwei Qianghuo Tang (Nine-Ingredient Notopterygium Decoction) and Shuangjie San (Double-Release Powder) can be discarded. True Shanghan is extremely rare nowadays; even if it occurs in severe cold, it should be treated as Internal Injury, let alone when not occurring in harsh seasons. I have established five methods to treat Internal Injury, leaving no gaps in the treatment of Heat Syndromes. Originally, sweat is the fluid of the Stomach; thus, the most critical point in Shanghan texts is the preservation of body fluids. When heat stagnates internally, body fluids are lost, making it impossible to generate sweat.

1. If the tongue coating is white and thorny, it indicates Lung disease. Use Shengmai San (Generate the Pulse Powder) added with Shengdi Huang (Rehmanniae Radix), Baishao (Paeoniae Radix Alba), Danggui (Angelicae Sinensis Radix), Huangqin (Scutellariae Radix), Gancao (Glycyrrhizae Radix), Chaihu (Bupleuri Radix), and Huanglian (Coptidis Rhizoma) to generate Metal and nourish Water.
2. If the tongue coating is black and slippery, it indicates Kidney Qi overwhelming the Heart. Use Bawei Yin (Eight-Ingredient Decoction). If black and dry, use Liuwei Yin (Six-Ingredient Decoction) to rescue Kidney Yin.
3. If the tongue coating is yellow, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) added with Huangqin or Huanglian to tonify Earth and generate Metal. If there is food retention, remove Huangqin and add Houpo (Magnoliae Officinalis Cortex) and Baizhu (Atractylodis Macrocephalae Rhizoma); do not remove Baizhu, and induce sweating regardless of food retention.
4. If the tongue feels stiff and immobile, fearing tongue rolling, use Xiaoyao San (Free and Easy Wanderer Powder) added with Huangqin, Danpi (Moutan Cortex), and Shengdi to nourish Water and benefit the Liver.
5. If the tongue is bright red, it indicates Heart Meridian disease. Use Liuwei Yin combined with Shengmai San to nourish Water and clear Fire.

Differentiation between Internal Injury and External Contraction, and between Cold and Heat, is based on tongue coating color. If black and slippery, it is Kidney Qi overwhelming the Heart; use Bawei Yin. If withered, black, and unmoistened, use Liuwei Yin; the patient will likely have floating redness on the malar eminences, and one dose will cause chills followed by sweating and recovery. If white turning yellow, or yellow turning black, it indicates Kidney overwhelming the Spleen; treat the Central Palace (Spleen/Stomach) with formulas like Buzhong Yiqi Tang. The Kidney corresponds to the Black Tortoise of the North, hence the color black. Below the position of Fire, Water Qi supports it; Water comes to save its Mother. If Fire is drained at this time, there is no outlet for Fire; assisting the Child to save the Mother means the enemy will inevitably retaliate. "Excess leads to harm, support leads to control"; the principle is clear. If gray, and scraping with fingernails yields no residue or juice, it is a Fire Syndrome, for which Huangqin and Huanglian are appropriate. If Kidney Qi overwhelming the Heart is treated with Huangqin and Huanglian, a human-character-shaped crack will appear on the tongue, leading to death. If black but not slippery, Kidney Water is dried up, requiring urgent rescue of Yin. When near a fierce flame, hands burn; as distance increases, it feels colder. This cold sensation is caused by the pressure of fire; similarly, a black tongue in heat diseases follows this logic.

Taiyang runs on the exterior of the body, specifically the back. The Three Yin run on the interior, specifically the front. Shaoyang is half-exterior and half-interior. (Note: Shaoyang runs along the side of the body and serves as the pivot of the Three Yang; twelve characters of scripture should be added here.) For instance, if the Central Palace needs tonification but pathogenic heat remains, combine Buzhong Yiqi Tang with Xiao Chaihu Tang (Minor Bupleurum Decoction) to treat Shaoyang, which is half-exterior and half-interior.

In treating Shanghan, regardless of the season or meridian, if fever persists for three to four days, Xiaoyao San should generally be administered. (It seems unreasonable for one formula to govern all seasons and meridians; however, external cold constraining internal heat creates Fire Depression. Since it is Fire Depression, Xiaoyao San can govern it. Jingyue's Liuchaihu Yin is based on this same principle.) If accompanied by food retention, combine with Xiao Chaihu Tang. (Combining with Xiao Chaihu Tang completes the Six Gentlemen composition, aiding the Spleen and digesting food. However, this applies to food retention before exterior release.) If excessive exterior-releasing treatments have been used, administer Xiaoyao San added with Shudi (Rehmanniae Radix Preparata) to rescue Yin. If fever lasts beyond eight or nine days, the tongue will likely be black (and dry, though some may be dry without being black), and the pulse will be flooding and rapid beyond measure. Administer Ren Shen (Ginseng Radix) 1 liang, Shudi 1–2 liang, and in severe cases, add Sanjiang (Ginger Preparata) 3 slices. (If Baihu Tang is mistakenly used here, Yang will have no anchor and death will follow immediately. A case record notes a patient who took Baihu Tang incorrectly, resulting in body heat like burning, thrashing several feet away, making examination difficult due to true Yang lacking foundation—a sign of impending collapse. Without immediate Ren Shen and Fu Zi, death would occur by midnight when sweating stops. Suddenly administering Ren Shen 1 liang, Paojiang (Prepared Ginger) 3 qian, Fuzi (Aconiti Lateralis Radix Preparata) 1.5 qian, Shudi 2 liang, Danggui and Baishao 3 qian each, Zhigancao (Prepared Licorice) 1 qian, with Jiang (Ginger) and Zao (Jujube) as guides, resulted in recovery after one dose, followed by gradual调理 (regulation). Append this as a warning against indiscriminate use of cold-cooling herbs. Adding 1–2 qian of Zhigancao to the formula is especially effective.) If accompanied by food retention, the face will be flushed with heat, breathing coarse, pulse firm and solid, mental state dull, and slight pain upon pressing the chest. (The tongue will have a thick, dry yellow coating.) Assess severity and use Xiaoyao San added with Shudi, starting from 4–5 qian up to 1–2 liang. (This refers to cases already subjected to exterior release. Extensive exterior release dries body fluids, causing retained matter to become dry and stuck, unable to exit. Heavy use of Shudi moistens Yin and Blood, allowing stool to pass naturally and retained food to descend.) If excessive purgative treatments have been used, mild cases require Sizijunzi Tang (Four Gentlemen Decoction) added with Danggui and Baishao, or large doses of Buzhong Yiqi Tang. Severe cases require Ren Shen 1 liang, Fuzi 3 qian, and Sanjiang 3 slices to induce sweating. (Excessive purging leads to loss of Yang; thus, Ren Shen and Fuzi are used to restore Yang. Once Yang returns, sweat produces itself. The term "loss of Yang" in excessive purging seems contrary to the classic statement "excessive purging loses Yin, excessive sweating loses Yang." However, here "Yang" should be viewed as Yang within Yin, making the logic consistent.) Then regulate with Sizijunzi Tang added with Danggui and Baishao.

Shanghan occurring in the eleventh or twelfth lunar month, or starting with aversion to cold, is an external contraction belonging to Exterior Syndromes, treated primarily with Qianhu Tang (Peucedani Decoction). If ineffective after two doses, use Xiao Chaihu Tang added with Zhishi (Aurantii Fructus Immaturus) and Jiegeng (Platycodonis Radix). If still ineffective after another two doses, continue with Xiaoyao San; recovery is assured.

If fever is accompanied by hypochondriac pain, deafness, dry mouth, and black tongue, it indicates unresolved pathogen. Use Xiaoyao San added with Danpi, Shengdi, and Jiulian (Pinellia Prepared with Wine) for 2–3 doses. If ineffective, it indicates Fire Dryness; use Shugan Yishen Tang (Soothe Liver and Benefit Kidney Decoction) or Guipi Tang (Restore the Spleen Decoction) added with Chaihu and Baishao. (Once dry, avoid further drying; remove Muxiang (Aucklandiae Radix) and steam Baizhu with rice water.) If heat is severe with pain, and swelling appears on hands, feet, head, and face (even forming scrofula-like lumps near the jaw), this is Wind generated by Fire Dryness, affecting the extremities. Use Zishen Qinggan Yin (Nourish Kidney and Clear Liver Decoction) with double the amount of Shudi as the main ingredient; cold-cooling herbs are contraindicated. (Two cases by Siming, treating Xu Yan's son and Jiang Zhonglian, were identical; consult them.)

For hard stools, consider Chengqi Tang (Downward-Pouring Decoction) only if it matches Zhang Zhongjing's criteria of epigastric fullness, dryness, excess, and hardness. However, true Taiyang Syndromes are rare today, and using the previous methods for Shanghan, such criteria are unlikely. Regardless of whether it is true Taiyang, if crude practitioners overuse exterior-releasing or purgative treatments, depleting true Yin and causing dry impaction, solely nourishing Qi and Yin will allow retained matter to pass naturally. (When Yin is depleted and stool is dry, nourishing Yin moistens it. Qi is also needed because propulsion is weak.) Comfort the patient not to rush for purgatives; waiting several days will yield results. (Though slow, this is stable and truly honors Zhang Zhongjing.) Some patients cannot defecate but can eat; pushing out the old and generating the new fills the granaries, leading to natural passage without worry. (Siming's treatment of Wu Bianyu is an example.) Others cannot defecate and cannot eat. Crude practitioners insist that clearing stool removes pathogen and clears the diaphragm, restoring appetite. (This view is limited; "shi" anciently meant feces. Crude practitioners, unaware of Qi deficiency and fluid depletion preventing transportation, still aggressively purge, delighted to see feces, hence called "Shi Yi" or Feces Doctors.) I disagree; first nourish the Stomach to support Righteous Qi, and supporting Righteous Qi removes pathogen. If nourishment is insufficient, pathogen does not leave quickly; lack of appetite is acceptable.

Regarding recurrent Shanghan, the world treats it as Excess, attributing it to food. They fail to realize that residual toxic heat lingers in the Yangming Stomach Meridian. After battle-sweat, Qi and Blood are severely depleted. Even if sweating is achieved by nourishing Yin, the effect reaches only 70–80%. Once the exterior is resolved, clarity returns. The remaining pathogen returns to Yangming, combines with food intake over one or two days, steams with the pathogen, and heat rises again. How to treat? Only by supporting Righteous Qi is there a way. At this time, heavy sweating causes sudden Qi deficiency; food digestion slows. The lingering pathogen combines with new food to create heat. Following contemporary physicians' tendency to attack pathogen would further deplete Qi and intensify heat, leading to sudden death. Instead, administer a large dose of Danggui Liujunzi Tang (Angelica Six Gentlemen Decoction). Even if symptoms and heat worsen, this indicates the pathogen and food are being expelled by the recovering Qi, a sign of emergence. Within three days, battle-sweat will resolve the condition. Using Fuling (Poria) and Huanglian to drain pathogen, or Zhishi and Houpo to digest food, guarantees death. Why does residual pathogen return to Yangming after 70–80% sweating? Because the Stomach governs muscles, and Qi is thin. Those with strong Qi do not suffer this. If pathogen lingers in muscles and bones, it is residual toxicity; treatment also prioritizes supporting Righteous Qi. For direct invasion of the Three Yin, use Lizhong, Zhenwu, or Sini categories based on syndrome differentiation. Sitting in cool pavilions or high halls in summer can also cause cold invasion; Fuzi Lizhong Tang should not be forbidden in midsummer due to seasonal bias. (Cold may also invade Jueyin and Shaoyin; treat by meridian.) Daiyang (Floating Yang) presents with pale red on malar eminences, migrating不定ly, not uniformly red face. Or restlessness, mania, desire to drink water, sitting/lying in mud/water; this is Yin Excess repelling Yang. Use large doses of Bawei Yin or Shenfu Tang. Ren Shen and Shudi can be used up to 1–2 liang; Fuzi up to 3–5 qian. Mistaking this for Baihu Syndrome leads to immediate death. (This syndrome is easily confused with subsequent Baihu Syndrome; misidentification determines life or death instantly. Differentiation must be precise.)

Heatstroke presents with red-purple swollen face, yellow whites of eyes, and thirst. Thirst always accompanies heatstroke. With red face, coarse breathing, restlessness, and mania, confirm Yangming syndrome before administering Baihu Tang (White Tiger Decoction).

Qianhu Tang (Peucedani Decoction): Qianhu (Peucedani Radix), Chaihu (Bupleuri Radix), Zisu (Perillae Folium), Jiegeng (Platycodonis Radix), Chenpi (Citri Reticulatae Pericarpium), Banxia (Pinelliae Rhizoma Preparatum), Baizhi (Angelicae Dahuricae Radix), Gancao (Glycyrrhizae Radix). Jiang (Ginger) and Zao (Jujube) as guides. Add Zhishi if food retention exists.

Chengqi Tang (Downward-Pouring Decoction): Dahuang (Rhei Radix et Rhizoma), Mangxiao (Natrii Sulfas), Houpo (Magnoliae Officinalis Cortex), Zhishi (Aurantii Fructus Immaturus). Removing Mangxiao yields Xiao Chengqi Tang (Minor Downward-Pouring Decoction). Removing Houpo and Zhishi and adding Gancao yields Tiaowei Chengqi Tang (Regulating the Stomach Downward-Pouring Decoction).

Zhenwu Tang (True Warrior Decoction): Fuzi (Aconiti Lateralis Radix Preparata), Baishao (Paeoniae Radix Alba), Fuling (Poria), Baizhu (Atractylodis Macrocephalae Rhizoma), Shengjiang (Zingiberis Rhizoma Recens).

Sini Tang (Reverse the Inversion Decoction): Fuzi (Aconiti Lateralis Radix Preparata), Ganjiang (Zingiberis Rhizoma), Gancao (Glycyrrhizae Radix). Doubling Ganjiang yields Bitong Tang (Unblocking the Tongue Decoction).

Shenfu Tang (Ginseng and Aconite Decoction): Ren Shen (Ginseng Radix), Fuzi (Aconiti Lateralis Radix Preparata). Removing Ren Shen and adding Huangqi (Astragali Radix) yields Qifu Tang (Astragalus and Aconite Decoction).

Baihu Tang (White Tiger Decoction): Shigao (Gypsi Fibrum), Zhimu (Anemarrhenae Rhizoma), Jingmi (Oryza Sativa), Gancao (Glycyrrhizae Radix). Adding Ren Shen yields Renshen Baihu Tang (Ginseng White Tiger Decoction).